HESI - Fundamentals Flashcards

Questions and Answers

What action should the nurse take when a client has questions about their medication?

Provide a list of Internet sites answering FAQs about medications.

Reassure the client that information is included in the written instructions.

Encourage the client to call the clinic nurse or health care provider. (correct)

Advise the client to get a current edition of a drug reference book.

During evacuation of a group of clients from a medical unit because of a fire, what should the nurse do if they observe an ambulatory client walking alone toward the stairway?

Assign an unlicensed assistive personnel to transport the client via a wheelchair.

Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.

Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Remind the client to walk carefully down the stairs until reaching a lower floor. (correct)

What should the nurse do after a needle stick occurs while removing the cap from a sterile needle?

Notify the supervisor of the department immediately.

Disinfect the needle with an alcohol swab.

Select another sterile needle. (correct)

Complete an incident report.

When emptying 350 mL of pale yellow urine from a client's urinal, what should the nurse do next?

Record the amount on the client's fluid output record. Signup and view all the answers

When administering medications through a feeding tube, what should the nurse do first?

Turn off the intermittent suction device. Signup and view all the answers

What should the nurse document when identifying placement of IV access in the client's right arm?

Right cephalic vein Signup and view all the answers

Which client statement indicates that the nurse should further assess the medication order?

This is a new pill I have never taken before. Signup and view all the answers

What action should the nurse implement when providing wound care instructions to a client who does not speak English?

Speak directly to the client, with an interpreter translating. Signup and view all the answers

The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.

True Signup and view all the answers

Which action is most important for the nurse to implement when obtaining a lie-sit-stand blood pressure reading on a client?

Stay with the client while the client is standing. Signup and view all the answers

Which intervention is best for the nurse to implement when a client becomes angry while waiting for a break to smoke?

Review the schedule of outdoor breaks with the client. Signup and view all the answers

Which serum laboratory value should the nurse monitor carefully for a client who has had a nasogastric (NG) tube to suction for the past week?

Sodium Signup and view all the answers

Which response is best for the nurse to provide to a client asking about drinking juice daily to prevent urinary tract infections (UTIs)?

Cranberry juice stops pathogens' adherence to the bladder. Signup and view all the answers

What respiratory rate should the nurse document after counting respirations over two different intervals?

16 Signup and view all the answers

Which health promotion brochure is most important for a client newly diagnosed with arteriosclerosis?

Decreasing Cholesterol Levels Through Diet Signup and view all the answers

What should the nurse implement first when a client reports not having a bowel movement in two days?

Assess the client's medical record to determine the client's normal bowel pattern. Signup and view all the answers

What instruction is most important for a nurse to provide to a client with redness in the sacral area?

Change positions in the chair at least every hour. Signup and view all the answers

What action should the nurse take next after inserting a urinary catheter and seeing no urine in the tubing?

Leave the catheter in place and reattempt with another catheter. Signup and view all the answers

What is the best nursing action regarding confidentiality when discussing a client's depression?

Discuss the client another time. Signup and view all the answers

What should the nurse do first after a client reports insomnia despite following relaxation techniques?

Ask the client to describe the routine he is currently following. Signup and view all the answers

Which action should the nurse take when an older client expresses confusion after consenting to surgery?

Assess the client's neurologic status. Signup and view all the answers

What is the priority assessment after an employee reports being struck by lightning?

Pulse characteristics Signup and view all the answers

What action should the nurse take when parental consent for a medication has not been obtained for a minor?

Do not give the medication and document the reason. Signup and view all the answers

Which action by the nurse is best for a client who has difficulty falling asleep?

Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. Signup and view all the answers

What priority action should the nurse take when a client states, 'I feel faint' and begins to fall?

Gently lower the client to the floor. Signup and view all the answers

How should the nurse respond when a client requests a pain pill while laughing at a television program?

Ask him to rate his pain on a scale of 1 to 10. Signup and view all the answers

What is the best response by the nurse when an obese client expresses concern about her sexual relationship?

Ask the client to talk about specific concerns. Signup and view all the answers

Based on the assessment finding of increased respiratory rate from 18 to 24 breaths/min, which intervention is most important for the nurse to implement?

Determine if pain is causing the client's tachypnea. Signup and view all the answers

What should the nurse do first upon being assigned to care for a close friend in the hospital setting?

Explain the relationship to the charge nurse and ask for reassignment. Signup and view all the answers

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?

Put bed rails up on the side opposite from the nurse Signup and view all the answers

What intervention has the highest priority in decreasing a client's risk of infection with partial-thickness and full-thickness burns?

Use of careful handwashing technique Signup and view all the answers

Which laboratory value is the most reliable indicator of chronic protein malnutrition?

Low serum albumin level Signup and view all the answers

Which action should the nurse take if the operative permit is not signed and the client has questions about surgery?

Inform the surgeon that the permit is not signed Signup and view all the answers

Which factor in a client's history poses the greatest threat for complications during surgery?

Taking anticoagulants for the past year Signup and view all the answers

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client Signup and view all the answers

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply)

Pull the auricle upward and outward Signup and view all the answers

Which instruction should the nurse provide to ensure optimal benefits from the use of a metered-dose inhaler?

'Compress the inhaler while slowly breathing in through your mouth.' Signup and view all the answers

Which action should the nurse take first when a client refuses to shower during their period?

Teach the importance of personal hygiene during menstruation Signup and view all the answers

What is the best response by the nurse when a client notes a reduction in sexual drive due to medication side effects?

'How will this affect your present sexual activity?' Signup and view all the answers

What should the nurse do next after a comatose client winces and pulls away from a painful stimulus?

Document that the client responds to painful stimulus Signup and view all the answers

The nurse plans to administer diazepam, 4 mg IV push. How many milliliters should the nurse administer?

0.8 mL Signup and view all the answers

Which intervention(s) is(are) correct when inserting a nasogastric tube for a client with hyperemesis? (Select all that apply)

Instruct the client to swallow after the tube has passed the pharynx Signup and view all the answers

Which observation indicates that a caregiver has learned how to use a gait belt for a client with right-sided weakness?

Standing on his wife's weak side Signup and view all the answers

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?

High risk for infection Signup and view all the answers

What client instruction is important for managing altered sleep patterns related to nocturia?

Decrease intake of fluids after the evening meal Signup and view all the answers

When performing sterile wound care, what is the best action if the saline solution labeled 'opened' is dated 48 hours prior?

Discard the saline solution and obtain a new unopened bottle Signup and view all the answers

Based on the nursing diagnosis of risk for infection, what intervention is best for an older incontinent client?

Maintain standard precautions Signup and view all the answers

What is the best action for a nurse when unable to distinguish the point at which the first sound was heard during blood pressure measurement?

Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading Signup and view all the answers

What action should the nurse take first if a client's blood pressure reading is 156/94 mm Hg?

Compare the current reading with the client's previous readings Signup and view all the answers

What is the most likely outcome of a malpractice lawsuit against a nurse who rendered aid after a motor vehicle collision?

There will be no judgment against the nurse, protected under the Good Samaritan Act Signup and view all the answers

Regarding informed consent for a client diagnosed with metastatic cancer, which legal principle is likely to be upheld?

TBD Signup and view all the answers

Which intervention should be included in the instruction to prevent complications of immobility?

Perform range-of-motion exercises to prevent contractures. Signup and view all the answers

Which method is best for the nurse to evaluate the client's ability to perform a dressing change at home?

Observe the client change the dressing unassisted. Signup and view all the answers

Which meal best meets the dietary needs of a client with cholecystitis?

Broiled fish, green beans, and an apple Signup and view all the answers

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

Retract the foreskin gently to cleanse the penis. Signup and view all the answers

The nurse should anticipate which change when a client's prescription is changed from the PO to IV route?

The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. Signup and view all the answers

Which action should the nurse implement for an older client who has had abdominal surgery and is requesting to go to the bathroom?

Assist the client to walk to the bathroom and do not leave the client alone. Signup and view all the answers

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

Mode of transmission Signup and view all the answers

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

Dorsiflex and plantarflex the feet 10 times each hour. Signup and view all the answers

In assisting an older adult client prepare to take a tub bath, which nursing action is most important?

Check the bath water temperature. Signup and view all the answers

In taking a client's history, which stool characteristic should the nurse report to the health care provider as soon as possible?

Daily black, sticky stool Signup and view all the answers

How should the nurse respond to a client who is very apprehensive about an IV line insertion?

Calmly reassure the client that the discomfort will be temporary. Signup and view all the answers

How should the nurse respond to a female client with terminal cancer who wishes to plan a party for her friends?

Planning a party and thinking about all your friends sounds like fun. Signup and view all the answers

Which observation requires the nurse's intervention when a UAP takes a client's blood pressure in the lower extremity?

The UAP auscultates the popliteal pulse with the cuff on the lower leg. Signup and view all the answers

During a clinic visit, which assessment data should the nurse obtain when a mother reports her 7-year-old child has sleep difficulties?

Description of the family's home environment. Signup and view all the answers

What should the nurse do when the IV rate for a dehydrated 2-year-old has slowed?

Check for kinks in the tubing and raise the IV pole. Signup and view all the answers

Which client is most likely to be at risk for spiritual distress?

Roman Catholic woman considering an abortion. Signup and view all the answers

Which intervention is most important for a client at high risk for the development of postoperative thrombus formation?

Encourage frequent ambulation in the hallway. Signup and view all the answers

Which nonverbal action should the nurse implement to demonstrate active listening?

Sit facing the client. Signup and view all the answers

A seriously ill client requests help to die. What is the best response for the nurse?

Talk with the client about her feelings related to her own death. Signup and view all the answers

Which document should the nurse use to develop nursing guidelines for a mental health services department?

ANA's Scope and Standards of Nursing Practice Signup and view all the answers

What action is most important for the nurse to implement for an adult male exhibiting flat affect and short answers after losing a life partner?

Encourage the client to see the clinic's grief counselor. Signup and view all the answers

Which response by the nurse is likely to encourage an older adult to assume total responsibility for insulin self-administration?

When I watched you give yourself the injection, you did it correctly. Signup and view all the answers

What should the client do if questions arise about their newly prescribed medication after getting home?

Contact your healthcare provider or pharmacist for clarification and guidance. Signup and view all the answers

Study Notes

Client Safety When Turning

Bed rails should be raised on the side opposite the nurse during client repositioning to prevent falls.
Grasping limbs or improperly using turning techniques can cause injuries.

Infection Prevention in Burn Clients

Handwashing is the most effective method to prevent infection in burn patients.
Administration of plasma expanders and topical antibacterial creams are secondary measures.

Indicators of Malnutrition

A low serum albumin level is a reliable indicator of chronic protein malnutrition.
Serum transferrin has a shorter half-life and does not reliably indicate long-term deficiencies.

Preoperative Protocol

The surgeon must be notified if the operative permit is unsigned, prioritizing consent and understanding.
Patient questions regarding the procedure should be addressed by the surgeon prior to signing.

Risks in Surgery History

Long-term anticoagulant use significantly increases the risk of surgical bleeding complications.

Safe Client Transfer Procedures

Positioning the chair at a 45-degree angle enables safe transfers; support should be offered on the weak side.
Clients should never be lifted under the axillae to prevent nerve damage.

Administering Ear Drops

Clients should be positioned on their side and auricle pulled upward and outward for effective medication delivery.
The dropper should be held approximately 1 cm above the ear canal.

Effective Inhaler Use

Medication should be inhaled through the mouth concurrently with the inhaler's compression for optimal effect.

Promoting Hygiene During Menstruation

Educating clients about personal hygiene during menstruation is crucial; their beliefs should be acknowledged.

Addressing Changes in Sexual Drive

Asking open-ended questions about the client's concerns regarding sexual activity allows for effective communication.

Glasgow Coma Scale Response

Documenting purposeful responses to pain is essential in neurologic assessments.

Medication Dosage Calculation

Calculating medication doses accurately is critical (e.g., diazepam 4 mg IV push equals 0.8 mL).

Nasogastric Tube Insertion

High Fowler's position and instructing swallowing are key steps in nasogastric tube placement.

Gait Belt for Ambulation Assistance

Caregivers should stabilize clients by standing on the weak side and behind the client for secure support.

Prioritizing Infections with Catheters

High risk for infection is the primary concern with indwelling urinary catheters.

Managing Nocturia

Suggesting reduced fluid intake in the evening helps manage nocturia effectively.

Proper Use of Sterile Solutions

Discard saline solutions labeled as opened beyond a 24-hour use limit to prevent contamination.

Infection Prevention for Incontinent Clients

Maintaining standard precautions is vital in reducing infection risk among vulnerable clients.

Blood Pressure Measurement Challenges

Deflating the cuff and waiting before reattempting ensures accurate blood pressure readings.

Blood Pressure Management

Comparing to past readings helps assess the significance of new high blood pressure readings.

Good Samaritan Law Protection

Actions taken in good faith at an emergency scene are typically protected from malpractice claims.

Healthcare providers must obtain informed consent; failure to do so can lead to negligence claims.

Client Monitoring During Blood Pressure Readings

Ensuring client safety through observation during standing blood pressure measurements is critical.

Managing Client Frustration

Reviewing the outdoor break schedule with the client can alleviate frustration regarding smoking breaks.### Nursing Actions and Rationale
Reviewing the schedule for outdoor breaks is crucial for maintaining client trust and communication.
Close monitoring of sodium levels is important for clients with prolonged NG suctioning due to potential fluid loss.

Patient Education

Cranberry juice is effective in preventing urinary tract infections (UTIs) by reducing bacterial adherence to the bladder.

Respiratory Assessment

Document the respiratory rate based on the most accurate count, which should not include interruptions from coughing.

Health Promotion

Focus on decreasing cholesterol intake as it is a significant risk factor for arteriosclerosis, more so than other factors such as smoking cessation or stress management.

Client Emotional Support

Engage directly with clients in distress to assess their situation and provide immediate support.

Bowel Movement Assessment

Assess a client’s normal bowel patterns before implementing interventions for constipation.

Pressure Ulcer Prevention

Encourage frequent position changes for clients to prevent pressure ulcers, particularly in wheelchair users.

Urinary Catheterization Procedure

If urine is not produced during catheterization, leave the initial catheter in place and attempt a second catheterization to correctly locate the bladder.

Maintaining Client Confidentiality

It is essential to discuss client issues in private to maintain confidentiality, avoiding discussions in public areas.

Sleep Promotion Techniques

Assess a client's current sleep routine before introducing changes to their care plan for insomnia.

Postoperative Client Monitoring

Assess neurological status if a client expresses confusion after signing a consent form to ensure understanding and legality of consent.

Initial Assessment Following Injury

First assess the client's pulse rate and regularity after being struck by lightning due to the risk of electrical injury.

Medication Administration for Minors

Withhold medication from minors until proper parental consent is obtained, ensuring documented reasoning for the decision.

Enhancing Sleep Hygiene

Incorporate a client's typical bedtime routine into their care plan to improve sleep quality.

Fall Prevention in Clients

Prioritize gently lowering a client who feels faint to the floor to prevent injury rather than seeking immediate medical assessment.

Pain Assessment

Utilize a pain scale to evaluate a client's pain experience, guiding appropriate medication administration.

Addressing Client Concerns

Invite clients to share specific concerns to facilitate open communication and effective counseling regarding sensitive topics like sexuality.

Respiratory Rate Interventions

Investigate the cause of tachypnea in postoperative clients, prioritizing the assessment of pain, anxiety, or fluid accumulation.

Professional Boundaries

Communicate openly with charge nurses about assignments involving close friends to maintain professional boundaries.

Immobility Complications Prevention

Perform range-of-motion exercises with immobile clients to reduce the risk of contractures and other complications.

Client Competence Evaluation

Assess a client's ability to perform self-care tasks like dressing changes through direct observation for accuracy.

Nutrition and Dietary Needs

Recommend low-fat foods for clients with cholecystitis to manage their dietary restrictions.

Hygiene Practices for Children

Gently retract the foreskin in uncircumcised boys over three years for proper cleaning to prevent infection.

Pharmacokinetics of Medication Routes

Transitioning medications from PO to IV can lead to a faster onset of action, as IV administration eliminates the absorption phase.### Patient Safety and Care
Assist clients to the bathroom for safety; never leave them alone.
Assess if clients need to void or have bowel movements, ensuring all safety measures are in place.
Bedpans may not be necessary if safety can be maintained.

Chain of Infection

Contaminated gloves can impact the mode of transmission in the chain of infection.

Preventing Venous Thrombosis

Instruct clients with limited mobility to dorsiflex and plantarflex their feet hourly to promote venous return. Other strategies like deep breathing, repositioning in bed, and hydration help but are less effective for this purpose.

Bath Preparation for Older Adults

Prioritize safety by checking the temperature of bath water for older adults to prevent burns or chills.

Stool Characteristics

Black, sticky stool (melena) is a critical sign of gastrointestinal bleeding and requires immediate reporting to healthcare providers.

Client Apprehension

Calmly reassure apprehensive clients about procedures, emphasizing that discomfort will be temporary.

Coping with Terminal Illness

Supporting clients’ plans for joyous activities, like parties, is important as it encourages goals centered around pleasure despite terminal diagnoses.

Blood Pressure Measurement

Apply a blood pressure cuff correctly to avoid inaccuracies; use the popliteal pulse when measuring in the lower extremities and expect a higher reading than in the arm.

Children's Sleep Patterns

Address potential environmental factors contributing to sleep disturbances in school-age children showing resistance to bedtime.

Managing IV Fluids in Children

Check for kinks and raise the IV pole to ensure proper IV flow in pediatric clients before taking further action.

Spiritual Distress Risk

Clients facing ethical dilemmas, such as a Roman Catholic considering abortion, may be at higher risk for spiritual distress compared to those facing decisions aligned with their faith.

Preventing Postoperative Thrombus

Encourage frequent ambulation for clients at risk of thrombus formation after surgery, as mobility is crucial for prevention.

Active Listening Techniques

Demonstrate active listening by sitting facing clients, maintaining open body language, and ensuring eye contact.

Assessing Client Feelings

When clients express feelings of despair, a nurse should assess their emotional state regarding death to provide appropriate support.

Mental Health Nursing Standards

Use the ANA's Scope and Standards of Nursing Practice to develop guidelines for mental health nursing.

Grieving Process Support

Refer clients in normal grieving to grief counseling, as it's an expected reaction to the loss of a loved one.

Encouraging Independence in Self-Care

Reinforce clients’ capabilities in self-administering medication by acknowledging their successful demonstrations rather than their anxieties.

Medication Queries

Advise clients to contact healthcare providers with any questions about medications for safe administration and individualized advice.

Emergency Fire Protocols

During fire evacuations, ambulatory clients should be reminded to walk carefully down stairs instead of relying on wheelchairs or elevators.

Needle Stick Protocol

After a needle stick incident, discard the involved needle and procure a new one; there’s no need to report if there was no contamination.

Urine Output Monitoring

Record the volume of urine promptly, and if it's within normal limits, no additional action is needed unless other symptoms arise.

Medication Administration via NG Tube

Always turn off suction before administering medications through a nasogastric tube to ensure full absorption.

IV Catheter Documentation

Use precise terminology to document the placement of IV catheters, ensuring correct identification of the site used.

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Test your knowledge in nursing fundamentals with these HESI flashcards. Each flashcard presents a scenario focusing on client safety during patient handling. Perfect for nursing students preparing for exams.